Healthcare Provider Details

I. General information

NPI: 1376158105
Provider Name (Legal Business Name): BENJAMIN LIUPAOGO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 09/09/2020
Certification Date: 09/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

REBEKAH CHILDREN'S SERVICES 290 IOOF AVE
GILROY CA
95020
US

IV. Provider business mailing address

REBEKAH CHILDREN'S SERVICES 290 IOOF AVE
GILROY CA
95020
US

V. Phone/Fax

Practice location:
  • Phone: 408-846-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: